December 31, 2008

Going Under

In December 2003, Brent Cambron gave himself his first injection of morphine. Save for the fact that he was sticking the needle into his own skin, the motion was familiar--almost rote. Over the course of the previous 17 months, as an anesthesia resident at Boston's Beth Israel Deaconess Medical Center, Cambron had given hundreds of injections. He would stick a syringe into a glass ampule of fentanyl or morphine or Dilaudid, pulling up the plunger to draw his dose. Then he'd inject the dose into his patient. If the patient had been in a panic before her surgery, Cambron would watch her drift into a pleasant, happy daze; if the patient had been moaning in pain after surgery, he'd watch the relief spread across her face as the pain went away. It was understandable, perhaps, that Cambron was curious to experience these sensations himself, to feel what his patients felt once the drugs began coursing through their bodies. It could even be considered a clinical experiment of sorts. "I had thought about it for a long time," he later confessed.

The way in which Cambron handled his own injection reflected that intense curiosity--but also a degree of caution. Although Cambron had been a physician for less than two of his 30 years, in that brief time he'd acquired a fund of knowledge that left him certain he knew what he was doing. With his patients, he typically delivered drugs intravenously, so that the medicine went directly into their bloodstreams and its effects were immediate. Now that he was delivering the drug to himself, he injected it into his muscle; that way, the morphine would have to seep through layers of fat and tissue before it began to circulate through his system, resulting in a slower, less intense, and presumably safer high. An intravenous injection, as one of Cambron's fellow residents would say, is like "putting fuel on a fire," but an intramuscular injection "is like putting a cookie in your mouth and letting it soak, so that you're not really chewing it and it's not getting into your stomach."

Cambron initially told no one of his decision to use morphine--not his colleagues, not even his live-in girlfriend, from whom he hid his syringes. What he was doing was illegal, and he knew others would disapprove. But his shame was leavened by a certain amount of confidence, even arrogance. During the 80-hour weeks he put in at Beth Israel, a Harvard teaching hospital considered one of the best in the world, he practiced medicine at its highest level. People could quibble with other choices Cambron might make, but if he chose to do something medical--even to himself--then it was, by definition, the right choice.

That first injection of morphine, however, would quite possibly be the last time Cambron actually chose to do drugs. As the needle broke the skin and the morphine slowly seeped into his system that December day, Cambron began to cede control over his own medical powers. Before long, his career--and much more--would be in jeopardy.

The common conception of anesthesiologists is that they do little more than put people to sleep while surgeons perform the true medical miracles. The reality of their job is more complicated--not to mention harrowing. In the course of putting a patient under, the anesthesiologist must maintain the patient's delicate physiological balance. Because the drugs he uses to put a patient to sleep often lower the person's heart rate and blood pressure, the anesthesiologist must administer other drugs to raise them. If the surgery requires silencing the patient's brain and paralyzing his muscles, then the anesthesiologist must control the patient's breathing, since the patient can no longer do so himself. During a surgery, in short, the anesthesiologist essentially takes over the patient's basic life-preservation functions.

As frightening as this process sounds, it routinely enables patients to undergo complex surgical procedures safely and without physical pain. Before the mid-nineteenth century, when anesthesia began to emerge as a medical specialty, this was rarely the case. Limbs were amputated and teeth extracted while patients were sentient and awake. Typical is a story recounted by a nineteenth-century Boston surgeon who helped treat a young man with tongue cancer: "The cancerous end ... was cut off by a sudden, swift stroke of the knife, and then a red-hot iron was placed on the wound to cauterize it. Driven frantic by the pain and the sizzle of searing flesh inside his mouth, the young man escaped his restraints in an explosive effort and had to be pursued until the cauterization was complete, with his lower lip burned in the process."

Among the doctors troubled by the pain and suffering he caused his patients was a young Connecticut dentist named Horace Wells. In December 1844, Wells attended a performance by Gardner Quincy Colton, a one-time medical student who had become a sort of scientific showman. Colton invited a volunteer from the audience to place in his mouth a wooden faucet connected to a rubber bag of nitrous oxide. After inhaling the gas, Colton's volunteer ran around the theater like a wild man, gashing his leg in the process. What intrigued Wells, according to Henry W. Erving's The Discoverer of Anesthesia: Dr. Horace Wells of Hartford, was that the volunteer seemed impervious to pain. As it happened, Wells needed to have his wisdom tooth removed. The next day, he had Colton give him a dose of nitrous oxide, after which one of Wells's colleagues performed the extraction. "I didn't feel it so much as the prick of a pin!" Wells reported. He went on to give nitrous oxide to more than a dozen patients, storing the gas in an animal bladder and then asking them to suck it into their mouths via a wooden tube while he held their nostrils shut.

A few years later, after some setbacks with nitrous oxide, Wells began to experiment with chloroform as an anesthetic. As with nitrous oxide, he experimented on himself. This time, though, Wells developed an addiction to it--which sent him into a downward spiral. At the age of 33, after being arrested, he inhaled some chloroform and then with a razor severed his femoral artery, bleeding to death.

Today, anesthesiology has obviously come a long way from Wells's animal bladder of laughing gas. But, for all its technological advances, the specialty is still plagued by an addiction problem among its practitioners. In 1987, the addiction medicine doctor G. Douglas Talbott reviewed the files of 1,000 M.D.s who had enrolled in the Medical Association of Georgia's Impaired Physicians Program. He wanted to know how the drug-addicted physicians broke down by age, gender, and, most importantly, medical specialty. What Talbott discovered, and subsequently published in the Journal of the American Medical Association, was disturbing: Although anesthesiologists made up only 5 percent of the physician population, they accounted for 13 percent of those physicians being treated for drug addiction. The numbers Talbott found for younger physicians were even worse: While anesthesia residents constituted 4.6 percent of all resident physicians, they accounted for 33.7 percent of residents in treatment for drug addiction.

No studies have found a correlation between the addiction rate and medical error (although in 2002, a 31-year-old Washington State woman suffered severe brain damage after her anesthesiologist, who was addicted to Demerol, allegedly mismanaged her care during a routine surgical procedure). But Talbott's article served as a wake-up call to the specialty nonetheless. In the 20 years since its publication, anesthesia departments have worked to educate their members about the risk of addiction; they've become more vigilant about monitoring access and use of drugs by members; and some have even instituted mandatory urine tests for practitioners.

And yet, the problem has persisted. A 2005 study that surveyed more than 100 anesthesiology residency programs found that, between 1991 and 2001, 80 percent of them had physicians who became addicted to drugs during their training, and nearly 20 percent reported one death due to overdose or suicide. "We've gone through lots of steps to try to make it harder and harder, and that hasn't seemed to have had a lot of impact," says Keith Berge, an anesthesiologist at the Mayo Clinic in Minnesota who sits on the American Society of Anesthesiologists (ASA) Committee on Occupational Health. "Addiction," a recent article in the ASA's journal Anesthesiology concluded, "is still considered by many to be an occupational hazard for those involved in the practice of anesthesia."

When Brent Cambron arrived in Boston in the summer of 2002 to start his residency at Beth Israel Deaconess Medical Center, he could legitimately claim to be one of the top young anesthesia doctors in the country--and that was before he'd even handled his first case. Anesthesia is considered one of the most competitive specialties, and the program at Beth Israel, with its Harvard affiliation, was even more rarefied. It selected just twelve residents that year, and those it chose were invariably at or near the top of their med school classes.

That was certainly true of Cambron, a handsome young doctor with close-cut brown hair, gentle green eyes, and a thin, athletic build. But in other ways he didn't fit the typical Beth Israel anesthesia resident profile. Unlike many of his colleagues, who hailed from major metropolitan areas on the coasts, Cambron had grown up in the no-stoplight town of Sperry, Oklahoma, about 15 miles north of Tulsa, the son of a data processor and a homemaker. After scoring off the charts on his ACT test and graduating as his high school class's valedictorian, he attended the University of Oklahoma on a scholarship, matriculating to the University of Oklahoma College of Medicine. From his days in Sperry to his time in med school, Cambron had always sailed to the head of the class with ease. "There were some people who had to put in fourteen hours or so to learn the material, but it always seemed like Brent could do it in about seven," recalls Matthew Paden, a medical school classmate. "People would be incredibly stressed out and sleep-deprived and pepped up on coffee, and then he'd come walking down the hall with a smile on his face on his way to ride his bike."

And yet, despite his whiz-kid status, Cambron seemed happiest when he came off as ordinary. "You kind of had to know him for a while to know how smart he was," says his college roommate John E. Thomas. "He didn't flaunt it." Although he was a gifted musician, the outlet he chose for his musical talents was a college party cover band called Hummer. Even in that, he was content to stay in the background, playing rhythm guitar and singing backup. "Brent was very much a behind-the-scenes, below-the-radar kind of guy," says James Suliburk, one of Cambron's bandmates who also went to college and med school with him.

When it came time to do his residency, Cambron chose anesthesia, which would provide him with good pay, reasonable hours, and plenty of intellectual and emotional challenges. In their need for constant vigilance, anesthesiologists are frequently likened to airline pilots: Both jobs entail long periods of boredom punctuated by moments of extreme terror. "From the moment you walk in the hospital until the moment you leave, you're waiting for disaster to happen, " says Ethan Bryson, an anesthesiologist at Mount Sinai hospital in New York. "And [when it does], you have to be ready to immediately intervene, recognize what's going on, and fix it, because someone's life depends on it."

As low-key as he liked to appear, Cambron craved this type of pressure. "If something was going to be difficult," says Thomas, "Brent always took it on." While most of his medical school classmates chose to do their residencies in Oklahoma, he decided to travel the great geographic and mental distance to Beth Israel.

Cambron immediately took to Boston. He rented an apartment on bustling Newbury Street, right in the heart of the ritzy Back Bay neighborhood, and attended concerts and Red Sox games. At the same time, he proved to be an excellent fit for Beth Israel. Even among the first-year residents, who typically work slavish hours, Cambron stood out for his penchant to get to the hospital early and leave late--something one fellow resident attributed to his "Midwestern work ethic." More importantly, during thelong hours he spent at the hospital, he impressed his colleagues with his clinical skills. "Sometimes a resident isn't born with what we call the 'oh shit gene' to recognize that something with a patient is quickly deteriorating," says Anthony Hapgood, a former Beth Israel anesthesia resident who was in the class ahead of Cambron's. "Brent wasn't like that. He could recognize when something was going wrong. He treated it early, and he treated it appropriately."

Cambron soon developed a reputation for levelheadedness during those moments of extreme terror--a levelheadedness that was rare not only in residents, but in more senior anesthesiologists, as well. Vivian Jung Tanaka, another of Cambron's co-residents, remembers the masterful way Cambron "ran codes"--medical jargon for leading the effort to resuscitate someone who's stopped breathing. "He was one of those unusual people that, no matter what happened, he kept his cool," she says. His placid demeanor was matched with a burning intelligence. "I think the first two years, he got the highest score on the practice board exam," says Suzanne Harrison, who was in Cambron's resident class.

In July 2004, Cambron's fellow residents and senior colleagues selected him to serve as a chief resident, one of the highest honors a junior physician can receive. By the time he received that honor, Cambron had been giving himself injections of morphine, fentanyl, and Dilaudid for nearly eight months.

The drugs most frequently used in anesthesia today--such as the opioids fentanyl and Dilaudid, as well as the sedative propofol--are among the most potent in the history of medicine. Dilaudid and fentanyl, for instance, are eight and 100 times more potent than morphine, respectively. These drugs aren't only powerful, they're also extremely addictive. Because they are chemically engineered to have short half-lives, so that their effects do not linger and patients can be safely discharged sooner after their surgeries, recreational users of such drugs quickly develop heightened tolerances to them, meaning that they have to use more and more of the drugs in order to achieve their desired highs. "There's a crash-and-burn phenomenon with these drugs," says Paul Earley, the medical director of the Talbott Recovery Campus in Atlanta, which specializes in treating impaired physicians. "Whereas an alcoholic physician or one who's abusing oral narcotics might not manifest obvious signs of addiction for years or even decades, it's common for anesthesiologists to show up in treatment six months or nine months or a year after their first time taking one of these drugs."

Cambron was no stranger to recreational drug use. According to a journal he kept, he was a heavy drinker in college and in medical school; he also occasionally smoked marijuana. But maintaining a hard-partying lifestyle in the midst of an ambitious academic career seemed like the type of challenge that Cambron thrived on. "We would go out and party all night and do the things college kids do," recalls one of Cambron's college friends, "and then he'd get up the next day and study for an hour and go take a midterm and ace it." When Cambron arrived in Boston for his residency, he cut back on his alcohol consumption. Soon, though, Cambron began to go out drinking on weekends with some of the people in his program. In December 2002, he found a resident who did cocaine and the two began using together. When his co-resident couldn't get cocaine, they would snort powdered Ritalin. In the year before he began injecting himself with opioids, Cambron was drinking three or four nights a week and using cocaine once or twice a month. Ironically, once he tried the morphine, he liked it in part because it allowed him to drink less.

When Cambron was appointed chief resident, it seemed to strengthen his conviction that, when it came to his drug use, he knew what he was doing. "I felt that things must be going well since everyone thought I was doing well," he later wrote in his journal. Not long after becoming chief, when Cambron began having trouble with his girlfriend (who had moved with him to Boston from Oklahoma), he increased the doses, along with the frequency, of his opioid injections. And the frequency increased even further after Cambron and his girlfriend broke up about halfway through his one-year term as chief. He started spending more time socially with the residents he supervised--including one, he discovered, who also took intramuscular injections of morphine. They began doing the drugs together. In January 2006, the resident revealed to Cambron that she had started taking the drugs intravenously. Soon he was giving himself regular i.v. injections of morphine, fentanyl, and Dilaudid and occasional injections of propofol.

For a time, Cambron was able to manage his drug use as he had in the past. Indeed, in July 2006, after he completed a fellowship in pain medicine, Beth Israel hired him as an attending physician and he became a clinical instructor of anesthesiology at Harvard Medical School. But, before long, the i.v. injections left him with cravings that he could only satisfy with ever larger and ever more frequent doses. It became harder for him to conceal what he was doing, and his work began to suffer. On one occasion, he fell after giving himself an injection of propofol, splitting open his forehead and leaving him with a black eye. The doctor who once got to work early and left late was now getting to work late and leaving early. Some of his colleagues told him he looked "disheveled."

In December, a senior physician approached Cambron and asked if he would meet with her after grand rounds the next day. When Cambron looked at the schedule, he realized that the grand rounds speaker was the director of the Massachusetts Medical Society's Physician Health Services, a group that assists physicians struggling with drug addiction. Cambron knew what was coming, but he came up with a plan. His resident friend--who had recently returned from an unsuccessful three-month stay at the Betty Ford clinic--had obtained clean urine for her own regular drug tests. He took some of her supply to work with him the next day. And when, after grand rounds, he was confronted with suspicions that he was using drugs, he agreed to produce a urine sample.

But Cambron could only avoid getting caught for so long. He continued to use more and more frequently, injecting himself before work and then taking syringes to use at the hospital. By the end of January, he was giving himself i. v. injections of Dilaudid throughout his days at the hospital and slurring his words for the five or so minutes after each hit. Officials at Beth Israel wouldn't comment on exactly how or when they discovered Cambron was using drugs, citing hospital policy not to discuss personnel matters, but, in early February, Cambron took a leave from the hospital to enter a rehabilitation facility in Virginia that specializes in treating impaired physicians.

On the night of July 3, 2007, Cambron put on blue hospital scrubs, rented a Zipcar, and drove 20 miles from the Back Bay to a hospital in the suburban town of Norwood, where he'd once done some part-time work. Four weeks earlier, he'd returned to Boston from the Virginia rehab facility. He was sober and committed to recovery--and to going back to his old job at Beth Israel. Although this would seem akin to, as one anesthesiologist friend of Cambron's put it, "sending an alcoholic to work in a bar," it is actually not uncommon. Anesthesiology residents who become addicted and successfully complete recovery are often then redirected toward lower-risk medical specialties. But those anesthesiologists who have finished their training (as Cambron had) are more typically permitted to return to the specialty, so long as they are monitored by an impaired-physicians program--something Cambron had agreed to.

But, not long after getting back to Boston, Cambron was summoned to a meeting at Beth Israel with the hospital vice president and the chair of the anesthesia department, during which they asked him to resign from the hospital staff and agree to a voluntary suspension of his license. (Cambron's resident friend had earlier agreed to these same conditions, although her medical license was ultimately revoked.) Cambron acquiesced, but he was devastated. "I felt betrayed by the people who were to have supported me," he wrote in his journal. A week or so later, Cambron snuck into Beth Israel, stole some propofol, and returned to his apartment, where he injected himself.

Now, as Cambron walked into the mostly empty Norwood hospital--his scrubs concealing the fact that he was, at that moment, prohibited from practicing medicine--he was once again determined to get sober. He carried with him used needles and some of his old supplies. He was going to throw them away. Even in the throes of addiction, he was still a physician and was a stickler when it came to the disposal of hazardous materials. "He was worried someone would get hurt going through the garbage," says Margaret Yoh, a Boston woman who was Cambron's girlfriend. But Cambron couldn't resist temptation. He swiped some propofol from an operating room, locked himself in a bathroom near the endoscopy unit, and injected the drug into his femoral artery. Before long a cleaning woman tried to gain entrance to the bathroom, but Cambron wouldn't come out. When he finally emerged over an hour later, hospital security officers were waiting for him. They noticed the blood on his hand, on his scrubs, and on the bathroom floor; they also noticed that Cambron was acting like, as one of them later put it, he was "on something." The security officers called the police. Cambron told them that he'd come to Norwood to pick up a bag for an anesthesiologist friend; the blood stains on his scrubs, he explained, were old. "I don't know why you keep questioning me," he protested. "This is no big deal." When they asked to search his backpack he refused. He was placed under arrest for trespassing and the officers then went through his bag, discovering a veritable pharmacy. He was charged with larceny and drug possession. At the police station, one of the officers asked Cambron if he was sick or injured. He told them he had the "disease of addiction." "To what?" the officer asked. "To everything," Cambron replied.

Cambron's father and his sister Kelly flew from Oklahoma to Boston to bail him out of jail. Kelly stayed at Cambron's apartment over the next several weeks to look after him. With a c.v. that now included a failed stint in rehab and an arrest record, Cambron seemed to have lost everything. But his medical license was still only suspended, not revoked, and he continued to hold out hope he could eventually return to anesthesia. He begged his sister to help him understand why he felt the need to use drugs in the first place. "He'd ask me if something went wrong in his childhood that he felt he'd need them," Kelly recalls. "I tried to help him figure that out and I couldn't. He was looking for any kind of reason for why he'd feel he needed them, because he couldn't figure it out, and it really bothered him."

The anesthesia specialty has been struggling with this question itself: Why do so many of its members suffer from addiction? The simplest--and most popular--explanation is access. Anesthesia is the only medical specialty in which physicians draw up, label, and account for their own drugs. As such, they have more opportunities than other physicians to abuse those drugs. "Anesthesiologists are left alone with open ampules of highly potent narcotics, " explains Berge, "and it's easy to divert for their own use." Cambron was proof of that. Beth Israel Deaconess Medical Center, according to its vice president for education Richard Schwartzstein, has multiple policies and procedures in place to prevent such diversion--including the requirement that anesthesiologists "waste" whatever drugs they don't use on a patient in front of a witness or that they return the unused drugs to the pharmacy, which are then verified through random tests. But these safeguards proved no match for a determined addict like Cambron. "Addicts are smart, we're smart; they're desperate, we're not desperate," says Berge. "So they're going to outsmart us every time."

In recent years, however, the access hypothesis has started to be questioned. Its leading critic is Mark Gold, a psychiatrist and the former chief of addiction medicine at the University of Florida's McKnight Brain Institute. "If it's just holding the drugs," says Gold, "the pharmacists have the drugs, so do drug-abuse researchers, and not many of them become drug abusers or drug dependent." In 2004, Gold presented an alternative hypothesis to explain anesthesiology's addiction problem: exposure. Using gas chromatography-mass spectroscopy equipment, Gold had researchers scour several working operating rooms for traces of anesthetic agents. Sure enough, even though the anesthetics were administered intravenously, the researchers found throughout the operating rooms trace amounts of fentanyl and propofol, which the patients had exhaled. The highest concentrations were found around the patients' heads--which is where the anesthesiologists typically sit during surgeries. Gold, who did some of the pioneering work on secondhand cigarette addiction during the 1990s, had his new hypothesis. "It wasn't a great leap," he explains, "to say, possibly, that some number of anesthesiologists who become drug abusers and drug-addicted may have as an important contributory factor exposure to secondhand drugs in the O.R. Their brains changed in response to the secondhand drugs, and they developed cravings as if they were taking the drugs themselves."

Most anesthesiologists and other addiction experts doubt exposure can explain the problem, since the amounts of anesthetics found in the operating room are so miniscule. "I think it's invoking an incredibly complex explanation for something that has a much more simple explanation," says Berge. And yet, even many of those who subscribe to the access hypothesis concede that it's unsatisfying. "I agree that access has something to do with it," says one anesthesiologist, "but people have to want to take advantage of that access. There has to be some other explanation."

Cambron's arrest started him on a vicious cycle of recovery and relapse. Over the next year, he would make numerous, serial attempts to get sober--again at the treatment facility in Virginia, at McLean Hospital outside Boston, and at a retreat in rural Connecticut that was started by Alcoholics Anonymous co-founder Bill Wilson. In each instance (including after he was arrested a second time, at Beth Israel), he would become sober for a while, before eventually, inevitably relapsing. In this, he was hardly unique. One 1990 study found that two-thirds of opioid-addicted anesthesiology residents who returned to their programs relapsed. Their continued access to drugs was surely a contributing factor, but there was something else that seemed to prevent their recovery.

The first of the twelve steps to sobriety is for the addict to admit that he is powerless over his addiction. The second step is to believe that a power greater than himself could restore him to sanity. But admitting this sort of powerlessness flies in the face of what makes someone a good anesthesiologist to begin with. Some anesthesiologists and addiction medicine specialists like to talk about what they call the "AOA disease"--referring to the Alpha Omega Alpha medical society, a sort of Phi Beta Kappa for med school students. Because only the top medical students are able to enter anesthesia residencies, it's a specialty stocked with overachievers. "They're driven and they don't know how to take care of themselves well, they're too compulsive about their work, they can't let cases go, they're almost wound too tight," Earley says of anesthesiologists. "And then, when the drug comes along, they just feel like, ahhhhhhhhh, I can finally relax. And it's in that experience that the setup for continued use occurs. If you've been wound tight all your life, the first time you use narcotics, you say to yourself, this is how normal people must feel." Raymond Roy, the chair of the anesthesiology department at Wake Forest University School of Medicine, relates some black humor that has made the rounds in anesthesia circles: "How can you avoid having any substance abusers in your residency? Recruit from the bottom of your med school class."

Compounding the problem is the fact that anesthesiology doesn't only draw overachievers but overachievers who, in order to succeed in the specialty, must also be control freaks--and, in particular, control freaks about drugs and the human body. "So much of what we do as a physician and as a specialist is control someone else's physiology," says Bryson. "We give what would be equivalent to a lethal injection on a daily basis if we didn't intervene. A lot of what we do is controlling the body's reaction to drugs. And I think that creates a false sense that, if we can control what's going on with somebody else, we should be able to control this in ourselves."

Cambron certainly seemed to suffer from that delusion. "He always told me that when he was taking these drugs, he knew exactly what he was doing," says his sister Kelly, "that whenever he messed around with stuff, because of his medical knowledge, he knew how much to do without going overboard."

Sometime in the night on October 13 or in the early morning hours of October 14, 2008, Cambron returned to the surgical suite on the third floor of the Beth Israel Deaconess Medical Center's Shapiro building. Once, the nine operating rooms there had been his professional home, where he'd work on knee repairs and breast biopsies and cataract surgeries. Now, they were simply a place where he could get drugs. Because the surgical suite in the Shapiro building was reserved for outpatient procedures, Cambron knew it would be empty at night. As he walked through the maze of hallways and through a series of imposing double doors, no one challenged his presence.

Cambron assembled his stash: It included five syringes, a 50-milligram vial of Demerol, four ten-milligram bottles of morphine, four ten-milligram bottles of Dilaudid, and a ten-milligram bottle of vecuronium--a muscle relaxant that, taken at high doses, will cause respiratory arrest in a matter of minutes. He brought all of it into a small room that bore the label "soiled utility" and was used to clean anesthesia equipment, closed the door, and began to inject himself.

At about 7:30 a.m., an anesthesia technician, who was making her morning rounds before the day's first surgery, opened the door. Cambron was sprawled on the floor between two stainless steel wash basins, his body surrounded by needles and empty vials, including, most ominously, the ten-milligram bottle of vecuronium. The technician ran for help and a team of doctors crowded into the small room. There was nothing they could do. At 7:47 a.m., a Beth Israel Deaconess anesthesiologist pronounced his former colleague dead. Cambron was 35 years old.

Two months later, with his death still under investigation by the police department, Cambron's friends and family don't know whether he meant to kill himself or whether his overdose was accidental. He left no suicide note, and he gave no signs that he was contemplating such an act. Indeed, he had recently arranged his apartment so that his girlfriend Yoh could move some of her things in. But the empty bottle of vecuronium is a haunting goodbye. After all, in spite of everything else that had gone wrong in his life, Cambron was an excellent doctor. Some of those who knew him have a hard time believing that he could have made such an elementary--and catastrophic--medical mistake.